HomeMy WebLinkAboutWELL-1-11-14448.TIF FROM : MORETZ WELL 2, PUMP FAX NO. : 7044521322 Mar. 21 2011 04:39PM P5
'� ^ . r ''" ¢1 RESIDENTIAL WELL CONSTRUCTION RECORD
4
y I f Nor.h Csrolina Department of Environment and Natural Resources- Division of Water Quality
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WELL CONTRACTOR CERTIFICATION fi 2586
1. WELL CONTRACTOR: f. DISINFECTION: Type /? Amount 5' C Z
Ashley T. Moretz g. WATER ZONES (depth):
Well Contractor (Individual) Name From /c2. To 95 i From To
Moretz WPl l f)ri 1 l in9 Fron1J29 TDJ3r) From To
Well Contractor Company Name From To From To
STREET ADDRESS 6159 HWY. 1 0 West G. CASING: Thickness/
Dept o D a ;n er WFig Mat t
Hickory NC 28602 From 4 To,4 Ft. 4!/ ✓L
City or Town State Zip Code From To Ft.
(7Q4 )- 46Z-1522 from To Fl.
Area code- Phone number
2. WELL INFORMATION: 7. GROUT: Depth Material Method
`, . ij / ` [/U From 0 To lo Ft. �AS l�
SITE WELL ID *if applicable) 14P^ / "/I - I / 7 q g From Q To 3 FL E li,,. { . : S
STATE WELL PERMITtt(u apphcabIu) From To Ft. /��
DWQ or OTHER PERMIT #(if applicable) C. SCREEN: Depth Diameter Slot Size Material
WELL USE (Check Applicable Boxy Residential Water Supply From Ft. in.
From To Ft. In. in.
DATE DRILLED / ^ 9" rr• To in. In,
TIME COMPLETED 3. U� l./ 0 . AM O PMl
9. SAND /GRAVEL PACK:
3. WELL LOCATION: / � / Depth Size Material
CITY: Terfc-i/ COUNTY (�tti 4r -w 0.. From Ft. _
q 3 7 7 e A ^ i lls Tu From To Ft.
QQ rl �'`[� Fro• To
(Street Name. Numbers. Community, Subdivision, Lot No., Parcel, Zip Cooe)
TOPOGRAPHIC / LANO SETYING: - 10. DRILLING LOG
❑Slope °Valley °Flat kAldge ❑Other FCOm Td r Fg rrna(ion De ription
(check appropriate boy) 0 a ! �• - �
LATITUDE 3 0 3 s� J, Q May b e i degrees,
1 r Q � = r
minutes. seconds or -
2 %% W in a decimal fr•rmar
LONGITUDE Q LL 1 h L .. Y � Grtti {(`
Latitude /longitude source: DGPS ❑Topographic map
(location of well must bo shown. on a USGS topo man ;me
attached to this form if not using GPS)
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d. WELL OWNER
OWNER'S NAME /I I/ A,
•
STREET ADDRESS
-0 rcl
!{ d City or
City or T State Zip Code
( )-
Area code - Phone number
11. REMARKS:
5. WELL DETAILS:
a. TOTAL DEPTH: 2 05 t
b, DOES WELL REPLACE EXISTING WELL? YES /NO ❑
e. WATER LEVEL Below Top I DO H 'AMA
CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE m+
P of Casing: ® FT. 1. N NCAC 2C, WELL CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS
(Use - #. if Above Top of Casing) RECORD HAS S EN PRQVIDED TO THE WELL OWNER,
d. TOP OF CASING IS / FT. Above Lend Surface' 7` /JA6 S ` AC 1
'Top of casing terminated at/or below land surface may require SIGNATURE O CERTIFIED WELL V C CONTRACTOR DATE
a variance in accordance with 15A NCAC 2C .0118. 'T"
e. YIELD (gpm): 30 _ METHOD OF TEST 18I r �t'' e , A /� ! • 41 ore_
PRINTED NA OF PERS d CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt., Form GW - 1a
1617 Mail Service Center — Raleigh, NC 27699 -1617 Phone No. (919) 733 -7015 ext 568. Rev. 7105